Not So Fast, Ladies: Annual Pelvic Exams May Be Unnecessary, But You Still Need Pap Smears

July 2, 2014

As a registered nurse with more than 16 years experience working with women in underserved communities, I’ve been utterly disheartened over the past 24 hours.

“Annual Pelvic Exams: Pretty Much Pointless?” trumpeted NYmag.com. “So Long, Stirrups? Doctors Group Nixes Routine Pelvic Exams” was NBCNews.com’s contribution to the discussion. Perhaps the worst offender was Slate with “Doctors Are Examining Your Genitals For No Reason.” This was accompanied by a photo of an enormous disembodied hand holding a metal speculum. As if health care providers are roaming the countryside and chasing women down city streets, brandishing their oversized silver speculi in their predatory eagerness. These broad-stroke headlines are both misleading and irresponsible.

Part of the problem is that these headlines lift the exact wording from the American College of Physicians’ Annals of Internal Medicine article and do not provide a larger context: “The ACP recommends against performing screening pelvic examinations.” But the Annals of Internal Medicine is a peer-reviewed medical journal, written for providers who understand that a pelvic exam and a pap exam are two separate although closely related procedures.

A pelvic exam is what most lay people understand to be the “in the stirrups” experience: the provider looks at the external genitals, examines the vagina and cervix using a speculum, removes the speculum and then inserts two gloved fingers into the vagina while pressing down on the patient’s abdomen. This is the overall procedure that the American College of Physicians is no longer recommending for healthy women with no symptoms.

The pap exam is a procedure that can be done during the middle part of the pelvic exam while the speculum is inserted; it involves the removal of some cells from the cervix and is used to detect early changes in these cells that might indicate cancer or a precancerous condition. The ACP article made no mention of changes to pap screenings and the American Cancer Society guidelines recommend that this procedure be completed at least every three years for most women over age 21, with additional recommendations related to age and previous abnormal pap results.

Since you can’t get a pap exam without the feet in stirrups experience, the pelvic exam has become synonymous with pap exam for many lay people. To trumpet The End of The Pelvic Exam Era without the differentiation might drive traffic, but it does nothing to contribute to the kind of nuanced conversation that needs to happen around women’s health. Additionally, these stories are neglecting or at least burying an important sub-clause of the recommendation. It doesn’t apply to women experiencing any type of symptoms.

Who does this sloppy journalism most affect? I spent more than a decade as a nurse home visitor working with first-time new moms (mostly teens) living in poverty. I've also worked in primary care in extremely underserved areas and now I do workshops mostly with LGBT-identified folks about how to access health care.

These articles reminded me of the hundreds of conversations I've had in the past years. Conversations encouraging women to make even a small step towards a first pelvic exam; women who have been sexually abused, gender-queer or transgender-identified people who have a cervix but who have to fight through multiple layers of gender dysphoria and body-based trauma to even consider getting it checked out. Women who feel so profoundly disenfranchised from the medical system that just walking into a provider’s office requires an act of tremendous courage. Uninsured or underinsured women or (more commonly now) women who have to make dozens of phone calls to find a gynecologist who takes their ACA insurance.

A few years ago, a group of medical provider friends became so concerned about the neglect of the pap exam in our queer communities that we arranged for a nurse practitioner to do a stirrups/speculum/pap exam on each of us. As part of a public performance. On stage, at a bar. An acquaintance later asked us if we thought we had changed anything. We all collectively shrugged. “We were just trying to demystify the experience,” one friend said. “It’s a start.”

Did Slate just undo all that work—the work of patients and providers both—with a single awful headline? Probably not. Public declarations that genitals are being examined for no reason may not influence the choices of women who are privileged enough to already be in conversations with their providers. They'll discuss the research and decide whether it makes sense for them to have a pelvic exam and they’ll still get the pap exam every three years. But for folks who are already struggling to access care, these public declarations will be one more reason to avoid the gyn’s office. Maybe for good—but certainly not for their good.